Autonomy in medical ethics after O’Neill

TLDR

Individual autonomy has long dominated bioethics, yet it is an aberrant concept that fails to provide a sufficient foundation for medical ethics. The authors propose revising the operational definition of patient autonomy for the twenty‑first century, advocating a principled model that requires clear information and space for patients to make responsible, considerate choices. They evaluate this model within the patient–doctor relationship, where mutual respect, an unspoken covenant, and bilateral trust are essential for honoring each party’s autonomy. The dominance of individual autonomy harms the patient–doctor relationship, replaces medical paternalism with an equally unacceptable bioethical paternalism, and may cause doctors to mistakenly equate uncritical compliance with patient requests to honoring autonomy while abandoning their professional duty.

Abstract

Following the influential Gifford and Reith lectures by Onora O’Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O’Neill in recommending a principled version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient–doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring “patient autonomy” when it is, in fact, abrogation of their duty as doctors.